Percutaneous Nephrostomy for Treatment of

Endourology and Stone Disease
Percutaneous Nephrostomy for Treatment of
Posttransplant Ureteral Obstructions
Seyed Abulghasem Mostafa, Shahin Abbaszadeh, Saeed Taheri,
Mohammad Hossein Nourbala
Introduction: We report our experience with percutaneous management of
urologic complications following kidney transplantation.
Materials and Methods: Of 1402 consecutive kidney transplant recipients
from living donors at our hospital, 21 required percutaneous nephrostomy
(PCN) for the treatment of obstructive lymphocele (n = 11), urinary calculus
(n = 8), and stricture of the ureterovesical junction anastomosis (n = 2). We
had also 11 kidney recipients with urine leakage from the ureter who were
treated only by indwelling ureteral catheter. Urinary complications were
diagnosed based on the clinical symptoms, elevated serum creatinine levels,
ultrasonography and renal scintigraphy. Patients with ureteral obstruction
or urine leakage were compared with kidney recipients without urologic
complications.
Results: A mean decline of 3.1 ± 3.0 mg/dL (range, 0.1 to 10.7 mg/dL) in
serum creatinine level was detected (P < .001) after PCN. All of the patients
remained symptom free for a mean follow-up period of 34.2 ± 20.1 months
(range, 3 to 81 months). Patient and graft survival rates were not different
between the patients undergoing PCN and other kidney recipients. The
only difference was the history of using antilymphocyte globulin which was
significantly more frequent in the patients of the PCN group (P = .01).
Conclusion: In our experience, PCN is a safe and effective method for the
treatment of ureteral obstructions in kidney allograft recipients. This method
provided long-term success with few recurrences and low morbidity and
mortality rates.
Keywords: kidney transplantation,
obstruction, percutaneous
nephrostomy
Urol J. 2008;5:79-83.
www.uj.unrc.ir
INTRODUCTION
Nephrology Research Center,
Baqiyatallah University of Medical
Sciences, Tehran, Iran
Corresponding Author:
Mohammad Hossein Nourbala, MD
Nephrology Research Center
Department of Kidney
Transplantation, Baqiyatallah
Hospital, Mullasadra St, Vanak Sq,
Tehran, Iran
Tel: +98 21 8126 4154
Fax: +98 21 8126 4157
E-mail: [email protected]
Received September 2007
Accepted December 2007
Urology Journal
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Stricture of the ureterovesical
junction (UVJ) anastomosis, with
reported incidence rates of 2% to
10%, is the most frequent urologic
complication in kidney allograft
recipients.(1-3) Significant stricture
is a serious complication which
can result in kidney failure and
permanent damage to the allograft.
Open surgery has traditionally
been used for correction of
Spring 2008
the obstruction; however,
open procedures are associated
with morbidity and delayed
convalescence. Development
of percutaneous modalities of
treatment such as percutaneous
nephrostomy (PCN) with low
complication rates has altered the
approach to ureteral stricture.
Percutaneous nephrostomy was
first described by Goodwin and
colleagues for temporary drainage
79
Percutaneous Nephrostomy for Posttransplant Ureteral Obstructions—Mostafa et al
in cases of hydronephrosis.(4) Nowadays, this
procedure is widely used for the treatment of
UVJ obstruction in individuals without renal
replacement therapy. However, small series
have reported the safety and feasibility of this
treatment method in ureteral complications
after transplantation.(5) This paper is a report on
the experience of an Iranian major transplant
center in correcting ureteral obstruction using
PCN.
MATERIALS AND METHODS
A total of 1402 kidney transplantation
procedures from living donors were performed
at our center between 1992 and 2002. Of the
allografts, 1305 (93.1%) were provided from
living unrelated donors and the remaining
97 (6.9%), from living related donors. In
a retrospective review of the clinical and
radiological records, we identified 21 recipients
(1.5%) who had undergone PCN for the
management of obstructive complications of
the ureter using the extravesical technique of
ureteroneocystostomy (Lich-Gregoir method)
with stent placement. Eleven patients with urine
leakage were treated by indwelling ureteral
catheter for 21 to 60 days without the need for
PCN or surgery. Clinical suspicion of urinary
complications was based on elevated serum
creatinine levels. In all cases, ultrasonography
was used to assess the status of the transplanted
kidney and the collecting system. Evidence
suggestive of ureteral obstruction and urine
leakage included ultrasonography findings of
hydronephrosis and presence of peritransplant
fluid collections, respectively. Renal scintigraphy
was also performed in 10 patients. Findings
suggestive of an obstruction included
hydronephrosis and delayed visualization of the
bladder and those suggestive of leakage were
detection of radionuclide activity outside the
collecting system.
In order to perform PCN, the puncture site
was chosen on the basis of the findings of
ultrasonography. Antegrade pyelography and
ureterography were performed with fluoroscopic
guidance. The PCN tube was removed when
patency of the ureteral stent was confirmed by
80
antegrade nephrostography and prior clamping.
The ureteral stents were removed with cytoscopic
guidance and the use of topical anesthesia about 3
months thereafter.
We defined and compared 2 groups of kidney
recipients who underwent PCN and those
without ureteral complications (control group).
Statistical comparisons were performed using
the chi-square and the Fisher exact tests for the
proportions and the t test and paired t test for the
continuous data. Survival analysis was done by
Kaplan-Meier method (death-censored analysis)
and differences were assessed using the log-rank
test. Data analyses for continuous data were also
repeated with the Mann-Whitney test to confirm
the results. A P value less than .05 was considered
significant.
RESULTS
Twenty-one patients underwent PCN, of whom
15 (71.4%) were men and 6 (28.6%) were women.
Their mean age at the time of the transplantation
was 40.0 ± 12.7 years (range, 18 to 70 years).
The mean interval between transplantation and
nephrostomy was 74.5 ± 94.0 days (range, 1 to
382 days). The mean serum creatinine values
before and after PCN were 5.8 ± 4.2 mg/dL
(range, 1.7 to 17.0 mg/dL) and 2.7 ± 1.9 mg/
dL (range, 1.0 to 7.5 mg/dL), respectively. The
patients experienced a mean decline of 3.1 ± 3.0
mg/dL (range, 0.1 to 10.7 mg/dL) in their serum
creatinine values (P < .001).
In the PCN group, 11 patients (52.4%) had
obstructive lymphocele with hydronephrosis.
Percutaneous catheter drainage of the
lymphocele for a period of 21 to 70 days relieved
hydronephrosis and lymphocele without the need
for further procedures. Two patients (9.5%) had
ultrasonographic features of UVJ obstruction.
Percutaneous nephrostomy relieved the
obstruction and serum creatinine values reduced
to the stable levels. Balloon dilation of the UVJ
obstruction and insertion of a stent in the ureter
for 3 months were performed in these 2 patients.
Eight patients (38.1%) had calculi and underwent
extracorporeal shock wave lithotripsy after PCN,
of whom 6 experienced complete clearance of
the calculus and 2 needed further interventions.
Urology Journal
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Percutaneous Nephrostomy for Posttransplant Ureteral Obstructions—Mostafa et al
All of the patients in the PCN group remained
symptom free for a mean period of 34.2 ± 20.1
months (range, 3 to 81 months). One patient died
111 months after PCN and 2 experienced kidney
failure 6 and 36 months thereafter. The Table
outlines demographic and clinical characteristics
of the patients in the two groups. The mean
follow-up period was 53.1 ± 27.5 months for the
kidney recipients in the PCN group and
56.2 ± 38.1 months for the recipients of the
control group (P = .70). Kaplan-Meier analysis
showed no difference between the two groups in
10-year patient and allograft survivals
(P = .40 and P = .90, respectively; Figures 1
and 2). The only difference was the history
of using antilymphocyte globulin which was
significantly more frequent in the patients of the
PCN group (P = .01)
100
80
Patient Survival
Percutaneous nephrolithotomy was performed
for these 2 patients through the PCN tract using
a 12-F Amplatz sheath and a 10-F ureteroscope,
which made them stone free.
60
40
Transplant Recipients
PCN
Controls
20
0
0
20
40
60
80
100
120
Posttransplant Months
Figure 1. Patient survival curve of kidney allograft recipients with
and without percutaneous nephrostomy.
Characteristics of Kidney Allograft Recipients With and Without Percutaneous Nephrostomy (PCN)
Characteristics
Age at transplantation, y
Sex, %
Male
Female
Transplant time, %
1
2
3
Transplantation side (right iliac fossa), %
Warm ischemia time, min
Cold ischemia time, min
Ureteral anastomosis technique (Lich-Gregoir), %
Positive panel reactive antibodies, %
Positive cytomegalovirus, %
IgG
IgM
Positive Epstein-Barr virus, %
IgG
IgM
Drugs, %
Ganciclovir
Antilymphocyte globulin
Mycophenolate mofetil-based triple therapy
Living unrelated donor, %
Donor sex, %
Male
Female
Donor age
Urology Journal
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Spring 2008
Group 1
(PCN)
40.0 ± 12.7
Group 2
(No PCN)
42.9 ± 13.6
.56
71
29
68.1
31.9
.58
94
5
0.3
89
17.2 ± 2.7
20.6 ± 10.5
99
7
.77
.88
.89
.46
.80
.90
40
5
35
2.5
.72
.53
25
0
24
1.6
.92
.64
30
30
65
75
14.5
10
55
81
.10
.01
.70
.65
100
0
0
90
17.2 ± 0.5
19.1 ± 1.7
95
7
90
10
28.1 ± 5.2
88
12
27.8 ± 5.2
P
.84
.54
81
Percutaneous Nephrostomy for Posttransplant Ureteral Obstructions—Mostafa et al
Transplant Recipients
100
Controls
PCN
Kidney Allograft Survival
80
60
40
20
0
0
1000
2000
3000
4000
5000
6000
Posttransplant Days
Figure 2. Death-censored graft survival curve of kidney allograft
recipients with and without percutaneous nephrostomy.
DISCUSSION
A number of studies have evaluated PCN in
the treatment of ureteral obstruction and urine
leakage in kidney transplant patients.(6-8) Ureteral
obstruction and leakage are the most common
urologic complications encountered in kidney
transplant recipients.(9-11) Most series indicate that
about 70% of the ureteral obstructions occur
within 3 months of transplantation and 80%
occur at the UVJ site.(2,12,13) Prompt diagnosis
and early treatment are critical for preventing
loss of the allograft and decreasing morbidity
and mortality. Ultrasonography and renal
scintigraphy can be used as initial diagnostic
techniques for assessing the patency and integrity
of the renal collecting system. Diagnosis of
the obstruction or leakage can be definitively
confirmed using percutaneous antegrade
pyelography.
Percutaneous approach should be considered
as a method of therapy for ureteral stricture
regardless of the severity of obstruction.(6)
Obstructions that occur soon after transplantation
are thought to be due to mechanical causes
including blood clots, calculi, edema, and ischemic
necrosis, whereas late obstructions are usually
the result of local or generalized fibrosis due to
ischemia or rejection.(4,11-15) Fibrosis detected in
late obstructions is less likely to resolve with
insertion of an intraluminal ureteral stent. We had
2 patients with late UVJ anastomosis obstruction
82
and ureteral stent insertion for 3 months, in
whom obstruction did not occur after stent
removal during the follow-up period.
As mentioned, PCN is a well-established
technique for rapid relief of ureteral obstruction
and improvement of the kidney function.
However, if this method fails, open surgery will
be considered which is associated with higher
mortality and morbidity rates. Repeated surgery
in the kidney transplant patient can be extremely
difficult and may result in graft loss and/or
significant blood loss if not performed by an
experienced surgeon. None of our patients needed
open surgery.
Leakage is usually the result of ureteral necrosis
as a consequence of rejection or vascular
insufficiency.(14-16) Aside from the 21 patients who
underwent PCN in our study population, there
were also 11 patients with leakage, all of whom
were treated by insertion of an indwelling ureteral
catheter for 21 to 60 days without the need
for PCN or surgery. The overall incidence of
posttransplant leakage and obstruction was 2.3%
at our center.
In the present study, we observed that most
of the cases with atypical transplant ureteral
strictures presented after more than 4 months
posttransplant. No case of death or nephrectomy
attributable to PCN occurred and the outcomes
were comparable to those of the kidney recipients
without urologic complications. One patient died
after about 9 years and 2 experienced allograft
rejection within 6 and 36 months after PCN. All
of the patients remained symptom free for a mean
duration of 34 months which represents excellent
results.
CONCLUSION
In our experience, PCN seems to be a safe
and effective method for treatment of ureteral
obstruction and leakage in kidney allograft
recipients. It provides long-term success with few
recurrences and low morbidity and mortality
rates. Indwelling stents may also be of use as a
measure to control urinary leakage and allow
stabilization of the immunocompromised patients
who are too ill to undergo the surgery.
Urology Journal
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Percutaneous Nephrostomy for Posttransplant Ureteral Obstructions—Mostafa et al
CONFLICT OF INTEREST
None declared.
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